Gender Identity, Gender Expression, and Sexual Orientation

Caring for Transgender and Gender Diverse Populations

Brandon Pollak, MD Assistant Professor Division of General Internal Medicine The Ohio State University Wexner Medical Center

Conflicts of Interest

• No industrial or professional conflicts of interest

Many of the treatments discussed regarding gender affirming hormonal therapy are considered “off label”.

1 Outline

• History/Background • Review of terminology • Health disparities • Ways to provide gender competent care • Linkage to gender affirming care

Objective 1

Understand differences between sex assigned at birth, gender identity, gender expression, and sexual orientation

2 Objective 2

Understand ways to provide a culturally competent, gender affirming, and patient centered visit for gender non-conforming (GNC)/transgender patients

Objective 3

Understand healthcare disparities in the GNC/transgender patient population

3 Objective 4

Become familiar with local and national resources to help patients with linkage to care for gender affirming therapies

History of Gender Diversity

• ”Two spirits” in Native American culture.1 • Hijras in South East Asia (India, Pakistan, and Bagladesh2,3)

Author: USAID

1) https://www.ihs.gov/lgbt/health/twospirit 2) https://www.theguardian.com/society/2014/apr/16/india- third-gender-claims-place-in-law 3) https://www.nytimes.com/2018/02/17/style/india-third- gender-hijras-transgender.html

4 • Hirschfeld and Ellis in the late 19th and early 20th century first described “transvestism” and started performing gender affirming procedures in the 1920s at Hirschfield’s Institute for Sexual Science in Germany (was later destroyed with Nazi occupation).1 • 1930s Dr. Harry Benjamin one of the first physicians to start prescribing cross gender hormones for patients. • 1979- Harry Benjamin International Gender Dysphoria Association (now World Professional Association for Transgender Health WPATH) formed to create standards of care when caring for transgender patients.

Joanne Meyerowitz. (2002). How Sex Changed: A History of Transsexuality in the United States. Cambridge, MA: Harvard University Press.

Background Background Roughly 0.6 to 0.7 percent of US population identifies as transgender 1 CDC cited a paper in 2017 that estimates there 1 million transgender persons living in the US.2 • Inherent difficulties with determining prevalence ‒ Gender identity not collected on US Census data ‒ Gender identity often not included in surveys or limited to binary gender (“are you male or female”) ‒ Gender experience is diverse, and definitions and terminology are rapidly evolving

1. Herman, J.L., Flores, A.R., Brown, T.N.T., Wilson, B.D.M., & Conron, K.J. (2017). Age of Individuals who Identify as Transgender in the United States. Los Angeles, CA: The Williams Institute 2. HIV/AIDS. (2018, November 30). Retrieved December 1, 2018, from https://www.cdc.gov/hiv/group/gender/transgender/index.html

5 Definitions and Terminology

• “There's a gender in your brain and a gender in your body. For 99 percent of people, those things are in alignment. For transgender people, they're mismatched. That's all it is. It's not complicated, it's not a neurosis. It's a mix-up. It's a birth defect, like a cleft palate.”

-Chaz Bono

• LGBTQ+ ‒ Lesbian, Gay, Bisexual, Transgender, Queer/questioning • Umbrella term • LGB focuses on sexual orientation • TQ+ focuses on one’s gender identity

Be aware, terminology used in the community is rapidly evolving and changing.

Source: Pixabay It’s ok to ask someone what a term means or for clarification if you are not familiar or don’t understand!

6 a) Cisgender “same”-One’s gender Gender Identity: identity and sex assigned at birth are One’s perceived experience of congruent their gender (male, female, non- b) Transgender “opposite or across”- One’s gender identity differs from sex binary etc.) assigned at birth. Umbrella term. c) Gender Diverse individuals- One’s gender identity falls outside of the gender binary of male or female. -Gender non-binary- Umbrella term for all genders other than Man/woman. Not all gender non-binary folks will identify as transgender -Agender- umbrella term in which one does not identify with either gender or may be gender neutral. -Gender fluid or Genderqueer-An identity commonly used by people who do not identify or express their gender within the gender binary. ***Transexual is an outdated term, and is often now considered derogatory by some individuals but referred to a transgender person who completed gender affirming surgical procedure(s). 1. “Definitions.” Trans Student Educational Resources, www.transstudent.org/about/definitions/.

7 Gender Expression: Outward portrayal of one’s gender -Examples of gender expression in identity masculine, feminine, or western culture androgynous, culturally defined. -Dress/clothing -Physical appearance -Modification of secondary sex characteristics -mannerisms, speech patterns Examples how transgender patients may express their gender a) Chest “binding”- wearing tight fitting braces to help create a flatter, more masculine chest appearance, minimize appearance of breast. b) “Tucking”- securing penis, scrotum and testes posteriorly with tape or a tightly fitting undergarments to maintain a flat front.

Sex Assigned at Birth -primary and secondary sex Biologic construct defined by genetic, characteristics anatomic, hormonal and physiologic characteristics Male, female, intersex -Sex/reproductive organs - Intersex or Disorder of Sex Development (DSD) - Disorders of sex development (DSD) are congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical 1 - Examples: Adrenal Congenital Hyperplasia, Androgen Insensitivity Syndrome. - Hermaphrodite is an outdated and derogatory term that should not be used. -”AFAB” or “AMAB” meaning Assigned Female at Birth etc. 1. Houk CP, Hughes IA, Ahmed SF, Lee PA Writing Committee for the International Intersex Consensus Conference Participants. Summary of consensus statement on intersex disorders and their management. International Intersex Consensus Conference. Pediatrics. 2006;118:753

8 Sexual Orientation: one’s physical, romantic, or emotional attraction to others. ‒ Heterosexual- “Who you love” Attracted to the opposite sex “straight” ‒ Homosexual- Attracted to the same sex “gay” ‒ Pansexual- Attracted to all sexes/genders ‒ Bisexual – Attracted to both men and women • Asexual- Lack of romantic or physical attraction to others. • Some transgender individuals may identify as gay, but majority often will not

Pronouns, matter! -The only way to know someone’s pronouns is to ASK them. -Some people do not use pronouns. -ALWAYS use a patient’s pronouns during communication regardless if patient is physically present. For example, when with talking with other members of the patient’s care team when Source: Trans Student Educational Resources the patient is not present, use their pronouns.

9 Additional terms • Drag queens and kings- people who dress in clothing associated with the opposite gender often in an exaggerated/theatrical fashion, part time. Does not imply anything about someone’s gender identity, sexual orientation etc. • Cross dressers or Transvestites- People who dress and adopt a presentation of the opposite gender for emotional or sexual satisfaction may live part time in the cross-gender role. • Queer- used to be considered a derogatory term (for some patients it might be) modern context refers to one whose sexual identity or gender identity falls outside of cultural norms, umbrella term.

• Kelly identifies as female and uses the pronouns she/her/hers. She was female assigned at birth. She likes to play sports and garden. She prefers to keep her hair shorter. She does not wear makeup and wears minimal jewelry. Kelly prefers to wear suits instead of dresses in professional situations. She is attracted to other Source: Trans Student Educational Resources women and identifies as a lesbian.

10 • Terry works 2nd shift at a local warehouse. He and his wife have two children. Terry was assigned female at birth and identifies as a transgender male. He uses the pronouns he/him/his. He feels most comfortable in jeans or t-shirts. He likes motorcycles and restoring cars. He is physical and emotionally attracted to women and identifies as heterosexual.

• Sidney is studying at a local university, studying biology with plans to attend vet school in the future. Sidney identifies equally with male and female genders and would consider themself genderqueer. Sidney likes to play video games, and likes to collect comic books. Occasionally they will wear some nail polish and light makeup. Sidney uses the pronouns they/them/theirs. They are not currently in a relationship but they are attracted to all genders and they consider themself pansexual.

11 Healthcare Disparities Among the Transgender Community

Health Disparities

“Denial of health care by doctors is the most pressing problem for me. Finding doctors that will treat, will prescribe, and will even look at you like a human being rather than a thing has been problematic. Have been denied care by doctors and major hospitals so much that I now use only urgent care physician assistants, and I never reveal my gender history.”

-Survey respondent from the National Transgender Discrimination Survey 2011

1. Institute of Medicine Committee on Lesbian Gay Bisexual, and Transgender Health Issues and Research Gaps and Opportunities . The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011. Available at: https://www.ncbi.nlm/.nih.gov/books/NBK64806. Accessed 11/28/2018

12 Health Disparities

• In 2010 National Institutes of Health (NIH) and Institute of Medicine (IOM) organized a committee to better understand the health care needs for the LGBTQ community and where knowledge and research gaps exist. • What effects the health of gender minorities?1 ‒ Stigma/transphobia ‒ Legal oppression /lack of protection ‒ Lack of LGBTQ experienced providers • Lack of robust LGBTQ+ curriculum in medical education • 50% survey participants reported having to teach their providers about transgender care2 ‒ Minority Stress Model (Brooks, 1981)

Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

• National Center for Transgender Equality and National Gay and Lesbian Task Force in 2011 conducted the National Transgender Discrimination Survey • Survey of 6,450 Transgender and gender non- confirming participants. • 19% reported experiencing homelessness at one point ‒ 15% of respondents lived in extreme poverty (4x higher than the general population) ‒ 57% experienced significant family rejection ‒ Unemployment rate of 14% (2x higher than national average at the time of survey) • 16% had some experience in underground work (including sex work and drug sales), highest in people who lost their jobs given bias (28%) • Transgender persons of color had even higher rates of working in the underground economy

13 • 41% of respondents reported attempting suicide, compared to 1.6 % in the general population1 • 19% reported being refused medical care1 • Rates of HIV 4x higher than the national rates.  Even higher among transgender people of color  In the 2015 US Transgender Source: Pixabay survey 1 in 5 black transgender women were living with HIV.2  CDC reports estimates among TGW, one quarter are living with HIV, and half of black/African American TGW are living with HIV.3 • 28% postponed medical care given fear of discrimination and 48% due to inability to afford medical care1

1. Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011 2.James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey . Washington, DC: National Center for Transgender Equality. Source: Pixabay 3. HIV/AIDS. (2018, November 30). Retrieved December 1, 2018, from https://www.cdc.gov/hiv/group/gender/transgender/index.html

Source: Pixabay

14 • 2015 US Transgender Survey (USTS) which was an anonymous online survey of 27,715 transgender adult respondents from all 50 states and US territories, conducted by National Center for Transgender Equality. • 40% of respondents have attempted suicide in their lifetime compared to 4.6% in the general population. ‒ Within the past year 7% of respondents had attempted suicide (0.6% national average). • Of the people who had seen a health care provider in the past year, 33% reported at least one negative experience related to being transgender. ‒ This included being refused treatment, verbally harassed, physically or sexually assaulted, or having to teach their provider in order to get appropriate care.

• 23% did not seek needed medical care because of fear of being mistreated related to their gender identity, 33% did not seek care because of affordability.

15 Local Health Care Experiences

• The 2015 USTS of the 27,715 respondents, 941 were from Ohio. • 1/3 experienced homelessness • 1/3 of those who saw a healthcare provider in the past year, had a negative experience related to their gender identity. • 15% reported a mental health professional or religious advisor tried to discourage them from being transgender.

2015 U.S. Transgender Survey: Ohio State Report. Source: Pixabay (2017). Washington, DC: National Center for Transgender Equality.

Providing Culturally Competent Care

16 “If there is not a place for me on your forms, there is not a place for me in your office” • Modify forms to allow patients to self identify gender identity • Use gender inclusive language on demographic forms ‒ Partner or spouse instead of husband/wife ‒ Parents/guardians instead of mother/father • Use a patient’s pronouns and chosen name at all times ‒ Always ask a patient’s preferred pronouns and chosen name as these often will be different on medical insurance cards and IDs. ‒ If you accidently misgender a patient or use their “dead” (birth) name, simply apologize and move on, do not dwell on this mistake! ‒ Clearly note these in the chart so other providers can access this information easily. ‒ Pay close attention to how your office will generate communications. Make sure the communication has proper pronouns and a patient’s chosen name. (i.e. computer generated letters). Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

“If there is not a place for me on your forms, there is not a place for me in your office” • Mirror the language your patient uses ‒ For example not all gender non-binary patients will identify as transgender, and some patients may identify as female rather than a transgender female etc . • Ask open ended questions and don’t make assumptions ‒ “Are you sexually active, what are the gender or genders of your sexual partners?” ‒ You can use phrases like “sperm producing” or “egg producing” partners when talking about contraception.

17 • Respect a Patient’s right to privacy. ‒ If you have learners in your clinic, always ask your patient if they are ok with a learner evaluating the patient, or being present during the exam. ‒ Even though it is often not the intent of the provider who has a learner, trans/GNC patients may feel like they are “medical spectacles” ‒ Even if your patient is open about being transgender in the office, this does NOT mean they are open in other situations as they may face discrimination, violence etc. Keep this information private in public domains. • During an exam be cognizant of dysphoria around organs/body parts. • Ex: Transgender men may prefer the term “top” or “chest”. • Ask a patient how they would prefer you to refer to certain body parts or organs. • Stick to what is relevant for the visit • If someone has a sore throat, you do not need to inquire about one’s surgical status

• Provide training to staff members on gender diversity ‒ Free online training available through multiple websites • HRC.org • LGBTHealthEducation.org • transhealth.ucsf.edu • Make sure there are gender neutral restrooms available for patients • Does your office have LGBTQ+ friendly signs/material in patient areas?

18 Health Maintenance • Cancer screenings ‒ limited evidenced based screening guidelines, still recommend screening for cancer based on organs present ‒ Transwomen with breast development will need breast cancer screening. • Likely a lower risk of breast cancer than ciswomen. Many providers will start screening at 50 and after at least 5 years of feminizing hormonal therapy. ‒ Transman will need pap smears if they have not had a hysterectomy, follow usual guidelines for cervical cancer screening. ‒ Transwomen will need prostate cancer screening discussions, again likely lower rates of prostate cancer than cisgender population. • STI/HIV screenings ‒ PreExposure Prophylaxis (PrEP) for HIV reduction • Depression screenings • Substances of abuse screening • Screening for history of abuse Deutsch, Madeline B. “Center of Excellence for Transgender Health.” Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Mental Health Considerations with Transgender and Gender Nonconforming Clients, transhealth.ucsf.edu/trans?page=guidelines-cancer.

Resources for Transgender and Gender Non-Conforming Patients

19 International Resources World Professional Association of Transgender Health (WPATH) https://wpath.org -Standards of Care v7 (guidelines for transgender care, gender affirming surgeries, gender affirming hormonal therapy)

National Resources University of California San Francisco Center of Excellence for Transgender Health http://transhealth.ucsf.edu/ -Transgender primary care guidelines including gender affirming hormonal therapy guidelines Fenway Health in Boston, MA https://fenwayhealth.org/ Largest LGBTQ+ Health Center in the US

Local Resources In Ohio TransOhio http://www.transohio.org/ Clinics: Equitas Health http://equitashealth.com/ Transgender Primary Care Clinic (Columbus) https://wexnermedical.osu.edu/pri mary-care/transgender-primary- care-clinic THRIVE Program (Columbus, OH) https://www.nationwidechildrens.o rg/specialties/thrive-program -Pediatrics and adolescents Pride Network (Cleveland, OH) https://www.metrohealth.org/prim ary-care/pride-network

20 Local LGBTQ Mental Health Resources Mental Health Services Equitas Health (Columbus and Dayton) www.equitashealth.com Clintonville Counseling and Wellness (Columbus) www.clintonvillecounselingandwellness.com Affirmations Counseling (Columbus) https://www.affirmationstherapy.com/